Nov 28 / Andrea Salzman, MS, PT

Reimagining Aquatic Therapy: Embedding Water Safety Without Sacrificing Skill: A Thought Leadership Article (Part 1 of 3)

Every week in America, thousands of children with disabilities miss swimming lessons.
Not because they cancel.
Not because they’re scared.
Not because the class is full.

They miss them because…
they were never signed up in the first place.

Not once.
Not ever. Why?

Why is Water Competency Second Tier?

Because in a family raising a child with autism, cerebral palsy, Down syndrome, or neuromotor delay, the weekly calendar isn’t a calendar -
it’s a battlefield.

PT on Monday and Friday.
OT & Speech on Wednesday.
Behavior therapy Thursday.
IEP meetings in between.
Insurance authorizations sprinkled like confetti.

And somewhere on that chaotic, color-coded, timestamped grid sits "not-drowning skills"-
a nice-to-have, a second-tier activity, a someday-maybe.

Except “nice-to-have” is a lie.
These kids are at the very highest risk of drowning.
Water competency should be a first-tier, non-negotiable safety skill.

But it never makes the calendar.

Why?
Because the medical needs always outrank the safety needs.
Because families are exhausted.
Because therapy eats the margins of every week.
Because adding one more thing feels impossible.

But here’s the part no one tells them:
The skills kids would learn in survival swimming and the skills therapists already use in aquatic therapy have a healthy chunk of overlap.

Breath control.
Balance reactions.
Rotational movement.
Vertical-to-horizontal transitions.
Sensory regulation.
Self-orientation in water.
Calm recovery at the surface.

Master clinicians already do this instinctively.
With the right system, novice clinicians could learn to do it intentionally.

So what if families didn’t need to choose?
What if water-safety foundations could be woven into medically necessary aquatic therapy - ethically and skillfully - as a system without changing the CPT code, the goals, or the clinical reasoning?

Not swimming lessons disguised as therapy.
Not therapists pretending to be coaches.
Just smarter therapy that protects kids and meets medical need.

Imagine a world where kids who never get signed up for swimming lessons
still come out of therapy knowing how to float, roll, orient, exhale, and recover. And their bodies are better for it.

No extra scheduling.
No extra cost.
No extra burden on families.

Just the most at-risk kids finally getting the safety skills
that should have been first-tier all along.

So What is the Solution?

Here’s the uncomfortable truth:
for a lot of our kids, therapy is the only guaranteed pool time they will ever have.

If that’s true, then water safety cannot live only in swim lessons.

So what if we did the obvious thing nobody seems to be doing:

We bake water-competency into the aquatic therapy we’re already providing.

For now, let’s call this idea: Foundational Aquatic Safety Techniques & Skills™ (FAST Skills™ as shorthand)

Working definition of Foundational Aquatic Safety Techniques & Skills™ (FAST Skills™) - The intentional integration of foundational, developmentally appropriate water-safety micro-skills into therapeutic activities, designed to improve a child’s orientation, breath control, postural security, hazard awareness, and capacity to make safe choices in aquatic environments — without providing swimming instruction and without altering the clinical goals, therapeutic documentation, or skilled nature of aquatic therapy.

FAST Skills do not make therapists into moonlighting swim instructors.

They don't encourage therapists to bill 97113 for “fun pool time” or random water play.

They don't dilute skilled intervention to become all things to all people.

Instead, it’s a therapist-centered way of integrating the building blocks of water competency - the same orientation, breath control, balance, and rescue-ready skills you see in the Halliwick Concept, water orientation models, and other established frameworks - into medically necessary aquatic therapy you’re already doing.

No new CPT code.
No change in goals.
No change in documentation or clinical reasoning.
Just a sharper lens:

“While I’m working on postural control, can I also give this child one more tiny piece of not-drowning?”

FAST Skills wouldn’t be created from scratch.
They would stand on the shoulders of giants - pulling from the Halliwick Ten-Point Programme, the global Water Competence frameworks, and survival-first models like Swim-to-Survive - and bring those hard-won foundations straight into the therapy pool.

It would take what already works and embed it (ethically, deliberately, and without watering down a single ounce of skilled care) so the kids who never reach a swimming lesson still leave therapy with the first real pieces of not drowning.

And maybe, just maybe, the most at-risk kids finally stop slipping through the cracks.

Because if therapy is the only guaranteed pool time a child will ever have,
then therapy is where safety has to begin.

Facts Map

FACTS MAPPED TO SOURCES
1. Water safety is deprioritized for children with disabilities

Fact Sources
  • Water competency is often deprioritized due to competing medical/therapy schedules. Cosart et al., 2025 [3]
  • Lack of adaptive swim programs, inaccessible facilities, and cost are major barriers to participation. Cosart et al., 2025 [3]; Carbone et al., 2021 [5]; Graham et al., 2025 [6]
  • Many instructors and programs are not prepared to safely support children with disabilities. Graham et al., 2025 [6]
  • Despite barriers, drowning is a leading cause of death in children with disabilities. Denny et al., 2021 [1]

2. Children with ASD, CP, Down syndrome, and neuromotor delay have dramatically elevated drowning risk

Fact Sources
  • Drowning is a leading cause of accidental death for children with ASD. Denny et al., 2021 [1]; Cosart et al., 2025 [3]
  • Children with ASD have up to a 40-fold increased risk of fatal injury, with drowning the leading mechanism. Cosart et al., 2025 [3]
  • Neurodevelopmental disabilities (ASD, CP, Down syndrome, neuromotor delay) are associated with markedly increased drowning and water safety risk. Denny et al., 2021 [1]; Cosart et al., 2025 [3]
  • Families prioritize medically necessary therapies (PT/OT/speech/ABA) over swimming lessons due to time, cost, and administrative burden. Cosart et al., 2025 [3]
  • Social, economic, and accessibility barriers reduce participation in recreational and aquatic activities. Carbone et al., 2021 [5]

3. Key survival swimming skills significantly overlap with aquatic therapy targets

Skill/Domain Evidence Source
  • Breath control, balance, rotational control, vertical↔horizontal transitions, self-orientation Halliwick Method evidence. Vodakova et al., 2022 [8]
  • Sensory regulation and adaptive behavior support. Alaniz et al., 2017 [4]
  • Motor skill and executive function improvements through aquatic therapy. Shariat et al., 2024 (systematic review/meta-analysis) [7]
  • HAAR and Halliwick address foundational aquatic readiness and safety domains. Vodakova et al., 2022 [8]
  • Aquatic therapy improves water safety behaviors and basic aquatic skills in children with ASD. Alaniz et al., 2017 [4]

4. Aquatic therapy can effectively teach water safety and aquatic readiness skills
Fact Sources
  • Halliwick-based programs improve aquatic skills in children with ASD. Vodakova et al., 2022 [8]
  • Aquatic group therapy improves water safety awareness and adaptive aquatic behaviors. Alaniz et al., 2017 [4]
  • Some aquatic therapy programs produce swimming-skill gains comparable to traditional instruction for children with disabilities. Alaniz et al., 2017 [4]; Vodakova et al., 2022 [8]
  • Aquatic therapy improves balance, motor skills, and functional mobility relevant to safe water participation. Pieniążek et al., 2021 [9]; Shariat et al., 2024 [7]

5. Embedding water competency into medically necessary aquatic therapy is feasible

Fact Sources
  • Aquatic therapy can incorporate foundational water safety skills within therapeutic goals. Alaniz et al., 2017 [4]
  • Halliwick-based and aquatic therapy interventions produce measurable gains in aquatic orientation and safety. Vodakova et al., 2022 [8]
  • Systematic reviews show aquatic therapy improves motor planning, self-regulation, and functional skills tied to water safety. Shariat et al., 2024 [7]
  • Pilot programs demonstrate structured aquatic therapy can improve safety skills without replicating swim lessons. Alaniz et al., 2017 [4]
  • Integration does not require CPT code changes (no evidence for incompatibility; no regulatory barrier identified). Absence of contrary evidence across all 9 studies

6. Recommended solutions for reducing drowning risk in children with disabilities
Solution/Approach Sources
  • Embed water safety skills into medically necessary therapy sessions. Alaniz et al., 2017 [4]; Vodakova et al., 2022 [8]
  • Leverage IEPs to include aquatic therapy or aquatic readiness goals. Carbone et al., 2021 (participation barriers and school-based recommendations) [5]
  • Increase therapist and instructor training on disability-specific aquatic readiness. Graham et al., 2025 [6]
  • Foster partnerships between rehab providers and recreation/swim programs to bridge access barriers. Carbone et al., 2021 [5]; Graham et al., 2025 [6]
  • Policy advocacy and public health awareness campaigns emphasizing drowning risk for neurodivergent children. Denny et al., 2021 [1]; Cosart et al., 2025 [3]

References
[1] Denny, S. A., Quan, L., Gilchrist, J., et al. (2021). Prevention of drowning. Pediatrics, 148(2), e2021052227. https://doi.org/10.1542/peds.2021-052227

[2] Munn, E. E., Ruby, L., & Pangelinan, M. M. (2021). Improvements in swim skills in children with autism spectrum disorder following a 5-day adapted learn-to-swim program (iCan Swim). Journal of Clinical Medicine, 10(23), 5557. https://doi.org/10.3390/jcm10235557

[3] Cosart, B. D., Lawson, K. A., Williams, S. R., et al. (2025). Parent perspectives on water safety for children with autism. Journal of Autism and Developmental Disorders. Advance online publication. https://doi.org/10.1007/s10803-025-06819-7

[4] Alaniz, M. L., Rosenberg, S. S., Beard, N. R., & Rosario, E. R. (2017). The effectiveness of aquatic group therapy for improving water safety and social interactions in children with autism spectrum disorder: A pilot program. Journal of Autism and Developmental Disorders, 47(12), 4006–4017. https://doi.org/10.1007/s10803-017-3264-4

[5] Carbone, P. S., Smith, P. J., Lewis, C., & LeBlanc, C. (2021). Promoting the participation of children and adolescents with disabilities in sports, recreation, and physical activity. Pediatrics, 148(6), e2021054664. https://doi.org/10.1542/peds.2021-054664

[6] Graham, K., Ostojic, K., Johnston, L., et al. (2025). Swimming for children with disability: Experiences of rehabilitation and swimming professionals in Australia. International Journal of Environmental Research and Public Health, 22(11), 1633. https://doi.org/10.3390/ijerph22111633

[7] Shariat, A., Najafabadi, M. G., Dos Santos, I. K., et al. (2024). The effectiveness of aquatic therapy on motor and social skill as well as executive function in children with neurodevelopmental disorder: A systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation, 105(5), 1000–1007. https://doi.org/10.1016/j.apmr.2023.08.025

[8] Vodakova, E., Chatziioannou, D., Jesina, O., & Kudlacek, M. (2022). The effect of Halliwick Method on aquatic skills of children with autism spectrum disorder. International Journal of Environmental Research and Public Health, 19(23), 16250. https://doi.org/10.3390/ijerph192316250

[9] Pieniążek, M., Mańko, G., Spieszny, M., et al. (2021). Body balance and physiotherapy in the aquatic environment and at a gym. BioMed Research International, 2021, 9925802. https://doi.org/10.1155/2021/9925802